| Autor: |
Floyd, Phyllis T., Oates, Jim C., Acker, Julie W., Warren, Robert W. |
| Zdroj: |
Perspectives in Health Information Management; Fall2022, Vol. 19 Issue 4, p1-10, 10p |
| Abstrakt: |
Not so long ago, defining the "medical record" was simple. It was the paper chart--volume upon volume that captured the serial, dutifully recorded events of a person's health care at a hospital or physician's office. Entries were typically handwritten, dated and timed, and signed in ink with title (i.e., authenticated). Errors were easily identified by an authenticated strike-through. Similarly, the paper chart was synonymous with the legal medical record (LMR). In other words, a patient's paper chart was that patient's LMR by definition, even if critical data was omitted or irrelevant data was included. Fast-forward to 2021 and the use of technology for capturing the record of a patient's care. Technology has brought new challenges as well as successes. For example, pervasive and persistent mythologies include that 1) a patient's electronic health record (EHR) is the LMR, and 2) patient-specific EHR printouts to paper or disc--or displays on monitors--are necessarily equivalents to the paper chart of the 1980s. Neither are true. We now must define at the outset what is included in the LMR/designated record set to ensure the accuracy of what is retained and released. [ABSTRACT FROM AUTHOR] |
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Supplemental Index |
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